Torres_ca by dredwardmark



Name: Torres, Benjamin Age/Sex: 58/M Address: 1641 – A Yakal St. Tondo Manila Date of admission: August 29, 2007 Admitting Diagnosis: NSTEMI CAD, HCVD, SB, NSR, E s/p explore lap for ruptured appendicitis Residents in charge: Drs.Dalanon/Gutierrez/Gregorio CIC: Palay/Rentillo/Roxas

Hospital #: 1729053

Clinical Abstract This is a case of a 58 year-old male who came in to IM-ER due to chest heaviness History of Present Illness Patient is a diagnosed case of hypertension for approximately 5 years taking Metoprolol and Felodipine with good compliance. HBP 190/100 UBP 130/80. 1 yr PTA, patient experienced on and off chest heaviness aggravated by exertion, nonradiating, 6/10 lasting for about 10 seconds and relieved spontaneously. No associated easy brusability, no PND, no orthopnea, no DOB. No consult done. 8 hrs PTA, upon waking up, patient noted chest heaviness, nonradiating lasting for 30 minutes, not relieved by rest. 6 hrs PTA, patient consulted at JRMMC and BP was noted to be 170/100. Patient given ASA and troponin I done was positive. Patient was advised admission and opted transfer to our institution hence this admission. Past Medical History s/p explore lap secondary to appendicitis – 2006 (-) DM, BA Family History (+) HPN – maternal and paternal side (-)DM,BA Personal and Social History 60 pack year smoker and alcoholic beverage drinker but stopped 3 years ago. Review of Systems General: no weight loss, no anorexia, no fever HEENT: no blurring of vision, no tinnitus, no dysphagia Respiratory: no cough, no colds GIT: no abdominal pain, no change in bowel habit. GUT: (-) dysuria, (-) hematuria, no oliguria Endocrine: no polyuria, no polydipsia, no polyphagia Neurologic: no seizure, LOC, no vomiting , no headache Physical Examination: Patient is conscious, coherent not in cardiorespiratory distress Vital Signs: BP: 170/90 HR: 64 RR:18 HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, no palpable neck mass, no NVE CHEST AND LUNGS: symmetrical chest expansion, no retraction, clear breath sounds HEART: adynamic precordium, AB at 6th ICS AAL NRRR, no murmur ABDOMEN: flabby, NABS, soft, nontender, no organomegaly, no mass EXTREMITIES: grossly normal no cyanosis with full equal pulse. (-) edema Assessment: NSTEMI CAD, HCVD, SB, NSR, E s/p explore lap for ruptured appendicitis Course in the Ward: Upon admission, Patient was placed on NPO except meds. He was hooked to IVF: D5W 500cc x KVO. Diagnostics requested were 12-lead ECGq6, CPK-MB q6/Troponin I quanti, CBC c PC, urinalysis, CXR- PA, FBS, BUN, Crea, Na, K, Mg, HDL, LDL, TG, cholesterol, BUA, 2D-echo with doppler. Therapeutics given were: 1. ASA 80mg/tab, 1 tab OD, after lunch 2. Clopidogrel 75mg/ tab OD 3. Captopril 25mg/tab TID 4. ISDN 5 mg/ tab TIDPRN for chest pain 5. Simvastatin 40mg/tab OD at HS 6. Nalbuphine 10mg/mL amp, ½ amp PRN IV for severe chest pain 7. Lactulose 30cc given at HS.

On the 2nd HD, vital signs were as follows: BP140/80, CR 72 RR 20 Temp 36.8 She was shifted to generalized liquid. Heparin drip was hooked. Captopril increased to 25mg/tab q6 as well as ISDN10mg tab TID. Other meds were continued. On the 3rd – 5th HD, vital signs were as follows: BP160-130/80-100 afebrile with normal respiratory and cardiac rate. NGT was inserted and gastric lavage done with clear fluid so NGT was eventually removed. Patient had (+) melena. Rpt CBC with platelet count and blood typing done. Heparin, ASA, Clopidogrel, on hold temporarily. Other meds given were tranexamic acid 500mg IV q8, omeprazole 40 mg IV OD, sucralfate 1g q6. Transfusion of 1 unit PRBC properly typed and crossmatched ordered but was eventually placed on hold since Hemoglobin was still 13.6g/dL. Isoket drip was was also started to run at 10 ugtts/min. Laboratory Results: X-RAY CHEST CARDIOMEGALY; AA Troponin I – positive Blood Typing – O+ Complete Blood Count Normal Values WBC 4.8-10.8 x 109 /L RBC 4.0-6.20 x 1012 /L Hgb 12-16g/dl Hct 37-47 % MCV 80-90 fL MCH 27-31 MCHC 32-36 Platelet 150-400 x 10^9/L Neutrophils 55-57 Lymphocytes 20-30% Monocytes 0-7% Eosinophils 0-3% Basophils 0-1% aPTT 60.9 Blood Chemistry Aug 30 BUN Creatinine Sodium Potassium FBS HDL LDL VLDL HDL RATIO TG Cholesterol BUA Calcium Magnesium Urinalysis Color Transparency Epithelial Cells Mucus Threads Amorphous Urates Pus Cells Erythrocytes Cast Albumin Sugar SG pH Bacteria Calcium Oxalate Aug 29 Yellow Clear Occasional Occasional Occasional 2-4 1-3 5.95 114 143 3.9 5.1 0.81 4.8

Aug 30 12.9 4.5 13.6 40 89.5 30.5 34 440 58.6 30.8 7.4 1.7 1.5

Aug 31 11.2 4.5 13.9 40.1 89.2 30.9 35 408 72.6 24 2 1 0.4

Sept 1 10.8 4.5 13.7 40.4 90.5 30.7 34 425 68.2 18 12.3 1.5 0

3.4 7.31 428.33 0.78

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